Breast Cyst Aspiration

Question:

The surgeon did a fine needle aspiration of two cysts in the same breast without any imaging. Is this billed once or twice?

Answer:

Fine needle aspiration of a breast cyst is reported per cyst. In this scenario, code 10021 with 2 units or 10021 and a second 10021 with a 59 or XS modifier as directed by your payor.

The fine needle aspiration codes are shown below.

Fine Needle Aspiration (FNA)

CPT Code	Description
10021	Fine needle aspiration; without imaging guidance
10022	with imaging guidance

Global Period for both codes – XXX*XXX means the concept of global period does not apply

*This response is based on the best information available as of 02/01/18.